Organization
OVER THE ROAD DENTAL
Active
Other names
Michel B. Haynie
Organization subpart
No
Provider details
NPI number
Authorized official
ANGIE BREEZE (OFFICE MANAGER)
(801) 886-9341
Entity
Organization
Contact information
Practice address
1953 W. CALIFORNIA AVE, SALT LAKE CITY, UT 84104
(801) 886-9341
(801) 886-1786
Mailing address
PO BOX 271069, SALT LAKE CITY, UT 84127-1069
(801) 886-9341
(801) 886-1786
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
143681-9922
UT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
545764459023
—
UT
Enumeration date
08/23/2006
Last updated
08/22/2020
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